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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209371
Report Date: 10/17/2023
Date Signed: 10/17/2023 11:09:59 AM


Document Has Been Signed on 10/17/2023 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:EVERGREEN COURTFACILITY NUMBER:
107209371
ADMINISTRATOR:ROYCHOUDHURY,MINAKSHIFACILITY TYPE:
740
ADDRESS:1415 WEST SCOTT AVENUETELEPHONE:
(559) 222-4876
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
10/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Minakshi Roychoudhury and Administrator, Shailesh PatelTIME COMPLETED:
11:23 AM
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On 10/17/2023, Licensing Program Analyst (LPA) Walton conducted an announced Pre-Licensing / Component III inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with Administrator, Minakshi Roychoudhury certificate # 6066638740, and Administrator, Shailesh Patel.

The facility is a 6 Bedroom and 2 Bathroom home and fire clearance was granted for 6, all residents may be Non-Ambulatory. This is a change of ownership inspection. There are 5 residents present during this inspection.

LPA toured the facility. Common areas were furnished and had adequate seating and lighting available. Bedrooms toured and had required furnishings. Hot water measured between 116.4 and 115.5 degrees F. LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Facility had an adequate supply of food. Cleaning supplies and chemicals were observed in a locked cabinet. Knives are locked in an upper cabinet near the refrigerator. Medications are locked in a cabinet in the kitchen. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 04/10/2023. Smoke detectors and carbon monoxide were observed to be operational.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. LPA reviewed resident and staff files.

Component III was conducted during today’s pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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